Down Payment "*" indicates required fields Legal Name* First Last Cell Number*Email* Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What Program are you interested in?* 1000 Hour Barber 1000 Hour Cosmetology 600 Hour Nail Tech 750 Hour Advanced Esthetician 800 Hour Manicure / Esthetician Combo License 320 Hour Lash Extension 300 Hour Crossover - Cosmetology to Barber (Must have an Cosmetology License) 300 Hour Crossover - Barber to Cosmetology (Must have an Barbers License) 500 Hour Massage Therapy – Coming Soon Class date you're interested in?*Which Enrollment Representative At Champions Academy has helped you?* Mr. Glen Mrs. Lorraine Have you already paid your Enrollment Fee and TDLR Student Permit? Yes No Down Payment Deposit Amount Payment Method* ACH - Routing and Checking Acct # Credit Card - 3.99% fee is applied Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Security Code Cardholder Name ACH* Account Number SelectSavingsChecking Account Type Routing Number Account Holder Name 3.99% Credit Card Fee Price: $0.00 Total Signature*Confirmation # 85897
